Healthcare Provider Details

I. General information

NPI: 1831239805
Provider Name (Legal Business Name): AMANDA LEIGH DALE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 A1A S SUITE 100
ST AUGUSTINE FL
32080-6591
US

IV. Provider business mailing address

505 WHISPERING CIR APT 13
ST AUGUSTINE FL
32084-0842
US

V. Phone/Fax

Practice location:
  • Phone: 904-806-6846
  • Fax: 904-471-6236
Mailing address:
  • Phone: 904-806-6849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 41898
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: